Annals for Hospitalists - October 2023
Authors: David A. Fried
Journal: Annals of Internal Medicine (2023)

Web ExclusivesOctober 2023Annals for Hospitalists - October 2023FREEDavid A. Fried, MDDavid A. Fried, MDFrom University of Michigan, Ann Arbor, Michigan (D.A.F.)Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AWHO202310170 SectionsAboutVisual Abstract ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Highlights of Recent Articles From Annals of Internal MedicineAtrial Fibrillation Recurrence in Patients With Transient New-Onset Atrial Fibrillation Detected During Hospitalization for Noncardiac Surgery or Medical Illness: A Matched Cohort StudyAnn Intern Med. 2023;176:1299-1307. Published 3 October 2023. doi:10.7326/M23-1411This matched cohort study (n = 139 pairs) evaluated patients hospitalized for noncardiac surgery or medical illnesses who had a transient, first-time episode of atrial fibrillation and followed them for 1 year after discharge. The study sought to determine the incidence of recurrent atrial fibrillation as diagnosed via electrocardiographic (ECG) monitoring and/or patient interview. The authors reported a higher incidence of postdischarge atrial fibrillation in the transient new-onset atrial fibrillation group (33.1% [95% CI, 25.3% to 40.9%]) compared with matched control participants (5.0% [CI, 1.4% to 8.7%]), with an adjusted relative risk of 6.6 (CI, 3.2 to 13.7). Results were similar when they excluded patients who received cardioversion in the hospital and those who only had reported rather than ECG-detected recurrent atrial fibrillation.Key points for hospitalists include:This study found that recurrence of atrial fibrillation is relatively common for patients whose first episode was transient and diagnosed during a hospital admission.Of the measured patient characteristics, only left atrial size was positively associated with atrial fibrillation recurrence.Prior studies did not utilize prospective ECG monitoring to assist in diagnosis of recurrent episodes. Patients in this study wore continuous cardiac monitors for 2 weeks at a time at 1 month and 6 months after discharge. Recurrence was also evaluated by telephone interview and chart review.Limitations include a small sample size, short duration of ECG monitoring, potential self-reporting bias, and residual confounding.Xylazine Adulteration of the Heroin–Fentanyl Drug Supply: A Narrative ReviewAnn Intern Med. 2023;176:1370-1376. Published 10 October 2023. doi:10.7326/M23-2001This narrative review provides an overview of the adulteration of illicit fentanyl with the veterinary sedative xylazine, including the pharmacology, clinical effects, and medical treatment of associated complications.Key points for hospitalists include:Xylazine is an animal sedative not approved for human use. It primarily works as a sympatholytic by stimulating α-2 receptors.It is now one of the most common adulterants of illicitly manufactured fentanyl in the Unites States. Suggested reasons for this include xylazine's low cost and possible synergism with fentanyl's psychoactive effects.Although commonly found in overdose victims, current research has not unearthed a causal correlation. Acute management of overdose is no different from that of fentanyl alone.Combined xylazine–fentanyl withdrawal may include irritability, anxiety, restlessness, and dysphoria and may complicate treatment of opioid withdrawal.For unclear reasons, severe ulcerating wounds may develop after use of xylazine, particularly on extensor surfaces, and lead to significant morbidity and mortality.Recommended wound care includes debridement, use of hydrogel, topical antimicrobial agents, and nonadhesive dressings. Editorialists discuss the importance of developing comprehensive surveillance of xylazine use and overdoses.In The Clinic: COVID-19Ann Intern Med. 2023;176:ITC145-ITC60. Published 10 October 2023. doi:10.7326/AITC202310170This article provides a narrative review of current recommendations regarding the prevention, diagnosis, and treatment of COVID-19.Key points for hospitalists include:Rates of severe disease have decreased due to vaccination; immunity from prior infection; improved treatments; and newer, less pathogenic variants.Groups with the highest risk for severe disease include anyone older than 65 years, residents of long-term care facilities, persons who are pregnant or recently postpartum, and persons with immunosuppression or underlying chronic medical conditions.Vaccines have proven essential in the fight against COVID-19. After preparation of this manuscript, the U.S. Food and Drug Administration provided an emergency use authorization for new, updated Moderna and Pfizer messenger RNA vaccines that include a monovalent component of the Omicron variant XBB.1.5. The Centers for Disease Control and Prevention recommends anyone older than 6 months get one of these vaccines. The only other available vaccine is Novavax (an adjuvanted recombinant protein monovalent vaccine), which has not received an update and is therefore only recommended to be given to persons who cannot or will not take a messenger RNA vaccine.No oral or intravenous medications are currently available for the prevention of COVID-19.Recommended treatment for hospitalized, high-risk patients with COVID-19 and without hypoxia includes remdesivir or nirmatrelvir–ritonavir. Patients with hypoxia should receive remdesivir, dexamethasone, and anticoagulants (at prophylactic or treatment doses depending on risk for venous thrombosis), with consideration of immunomodulators, such as tocilizumab and baricitinib, for those with rapidly progressing disease.The Latest Highlights From Journal ClubCan a standardized 3-minute patient interview detect delirium in the hospital?The 3D-CAM 3-minute interview has 92% sensitivity and 95% specificity for detecting delirium in various care settingsAnn Intern Med. 2023;176:JC107. doi:10.7326/J23-0064This systematic review and meta-analysis of 7 studies found that the abbreviated 3-minute diagnostic interview for confusion assessment method–defined delirium has a pooled sensitivity of 92% and specificity of 95% in medical, surgical, postanesthesia care unit, and intensive care unit hospital settings.Are direct oral anticoagulants (DOACs) as effective as low-molecular-weight heparin (LMWH) in the prevention of recurrent cancer-related venous thromboembolism (VTE)?In adults with cancer and VTE, DOACs were noninferior to LMWH for recurrent, nonfatal VTE at 6 moAnn Intern Med. 2023;176:JC104. doi:10.7326/J23-0067This randomized controlled trial of adult patients with cancer and VTE (n = 671) better approximated real-world prescription behavior than prior trials and found that DOACs were noninferior to LMWH in preventing recurrent VTE and were associated with higher rates of nonmajor bleeding (3.2% difference [CI, 0.1% to 6.3%).Does kidney function modify the effect of empagliflozin in patients with heart failure (HF)?In chronic HF, empagliflozin reduced a composite of CV death or HF hospitalization across kidney risk categoriesAnn Intern Med. 2023;176:JC101. doi:10.7326/J23-0065This pooled patient-level analysis of 2 randomized controlled trials of patients with HF (n = 9718) showed that empagliflozin reduced the composite outcome of cardiovascular (CV) death or HF hospitalization regardless of kidney function, including patients with estimated glomerular filtration rates as low as 28.5 mL/min/1.73m2.Is dapagliflozin safe and effective for patients with HF and peripheral artery disease (PAD)?In HF, with or without PAD, dapagliflozin reduced a composite of worsening HF or CV death and did not increase amputationsAnn Intern Med. 2023;176:JC99. doi:10.7326/J23-0066This pooled patient-level analysis of 2 randomized controlled trials of patients with HF (n = 11 005) showed that dapagliflozin reduced the composite outcome of CV death or worsening HF in patients with PAD (hazard ratio [HR], 0.71 [CI, 0.54 to 0.94]) and without PAD (HR, 0.80 [CI, 0.72 to 0.88]) and did not increase the risk for amputation (nonsignificant HR of 0.87 in both groups).Sign up here to have Annals for Hospitalists delivered to your inbox each month. Comments 0 Comments Sign In to Submit A Comment Author, Article, and Disclosure InformationAuthors: David A. Fried, MDAffiliations: From University of Michigan, Ann Arbor, Michigan (D.A.F.)Disclosures:The author has reported no disclosures of interest. Forms can be viewed at https://rmed.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M23-1807. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics October 2023Volume 176, Issue 10 ePublished: 17 October 2023 Issue Published: October 2023 Copyright & PermissionsCopyright © 2023 by American College of Physicians. All Rights Reserved.Loading ...